Dental plans can be a very desirable employee benefit, because many medical plans don’t provide dental coverage, so it must be purchased separately. But, not all dental plans are equal. We can make sure your coverage is set up right to cover the dental services you use, and prevent surprises at the dentist’s office.
The four main types of dental coverage are:
- Dental Health Maintenance Organization (DHMO) Like an HMO, a DHMO features a primary care dentist. Patients must generally see dentists within the DHMO network to receive coverage.
- Preferred Provider Organization (PPO) or Participating Dental Network (PDN). Patients in these types of plans may generally see any licensed dentist. However, choosing a dentist within the PPO or PDN network may cost less.
- Dental Indemnity. Dental indemnity plans allow patients to see any licensed dentist. Patients pay a deductible and coinsurance.
- Table or Schedule of Allowance Plan is based on a list of covered services with an assigned dollar amount. That fee is the amount the plan will pay for those services that are covered. The patient pays the difference between what the dentist charges and what the plan will pay.
Dental Expenses and Health Savings Accounts (HSAs)
Dental expenses are generally considered qualified medical expenses under a Health Savings Account.
Dental Plans and COBRA
COBRA (Consolidated Omnibus Budget Reconciliation Act) requires some employers to provide covered employees and their family members the right to continue group health benefits, including dental coverage, for a limited time after coverage would otherwise end. COBRA applies to employers who sponsor a group health plan, and have 20 or more employees on more than 50% of their typical business days in the prior year.
Dental Coverage and HIPAA
The federal Health Insurance Portability and Accountability Act (HIPAA) includes protections that limit exclusions for preexisting conditions, prohibit discrimination against employees and dependents based on health status, and allow special opportunities for individuals to enroll in a new plan under certain circumstances.
HIPAA does not apply to plans with "excepted benefits." Dental-only coverage may be considered limited-scope excepted benefits and, therefore, not subject to HIPAA if the benefits are offered under separate coverage or the benefits are "not an integral part of the plan."
For plan years beginning on or after January 1, 2015, final rules eliminate the requirement for participants to pay an additional premium for limited-scope dental benefits to qualify as benefits that are "not an integral part of a plan." In addition, in order to meet this criterion, such benefits:
- Do not have to be offered in connection with a separate offer of major medical or "primary" group health coverage under the plan.
- Can be provided without connection to a primary plan, or the benefits can be offered separately from the major medical or "primary" coverage under the plan, as provided in the rules.
Medicare and Dental Care
Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Medicare may pay for dental services that are an integral part of a covered procedure (e.g., reconstruction of the jaw following accidental injury) or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare may also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.